TEEN AFTER SCHOOL PROGRAM REGISTRATION PACKET

Transcription

1 ATTN: Abbey Davis Teen & Volunteer Director P: F: TEEN AFTER SCHOOL PROGRAM REGISTRATION PACKET NAME OF PARTICIPANT: DATE OF COMPLETION & SUBMISSION: DESIRED START DATE: Note: Registration is not complete without first month s payment. If paying by check, a voided check must be provided in addition to first month s payment. FOR OFFICE USE ONLY Registration packet received on: Received by: Registration Packet Complete: YES NO

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3 TASP REGISTRATION FORM TEEN AFTER SCHOOL PROGRAM (5TH 8TH GRADE) PARTICIPANT INFORMATION LAST NAME: FIRST NAME: GRADE (2014/15): AGE: GENDER: M F D.O.B: HOME ADDRESS: CITY: ZIP: SCHOOL ATTENDING: PARENT/GUARDIAN INFORMATION (PRIMARY) LAST NAME: FIRST NAME: HOME ADDRESS: CITY: _ ZIP: HOME PHONE NUMBER: CELL/WORK: PARENT PARENT/GUARDIAN INFORMATION (SECONDARY) LAST NAME: FIRST NAME: HOME ADDRESS: CITY: _ ZIP: HOME PHONE NUMBER: CELL/WORK: PARENT ATTENDANCE DAYS (PLEASE CIRCLE THE DAYS YOUR CHILD PLANS ON ATTENDING) MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY TRANSPORTATION Would you like to utilize the Ann Arbor Y bus service from your child s school to the Ann Arbor YMCA (check one): YES please NO thank you REGISTRATION FORMS TO BE COMPLETED AND TURNED IN *Registration is not complete until all forms are completed and first month s payment is made. Registration Form Participant Code of Conduct First Month s Payment Parental Acknowledgement Parental Sign Out Consent Form Monthly Automated Payment Agreement Permission & Health Form 3

4 TASP PARENTAL ACKNOWLEDGEMENT TEEN AFTER SCHOOL PROGRAM (5 TH - 8 TH GRADE) PARENT HANDBOOK ACKNOWLEDGEMENT I acknowledge that I have read the parent handbook and I am fully aware of the Teen After School Program s philosophy, policies and procedures. I have read and understand the tuition and fee arrangements as well as all of the conditions detailed in this handbook. I have read that bus pick up availability will be determined at least one week prior to school year start date once registrations determine demand for bus transportation and from which schools. Director Signature PHYSICAL HEALTH PARENTAL ACKNOWLEDGEMENT This acknowledges that my child,, who attends the Ann Arbor YMCA School Age Child Care Programs, licensed/approved by the Division of Child Day Care Licensing, is in good health. Further, any health restrictions, allergies, medications taken by the child, or any other needs are in fact noted below and listed on the health information form. Immunization records or appropriate waivers are up to date and on file with my child s school. Please use this space to provide any pertinent medical information for the Ann Arbor Y: Director Signature 4

5 TASP PARTICIPANT ACKNOWLEDGEMENT BEHAVIORAL CODE OF CONDUCT (TO BE COMPLETED BY TASP PARTCIPANT & PARENT) TEEN AFTER SCHOOL PROGRAM (5TH 8TH GRADE) The purpose of the Behavior Code of Conduct is to provide a safe, productive and fun environment that aligns with mission and goals of the Teen After School Program. I,, as a participant of the Teen After School Program have carefully read the Parent & Participant Handbook and am fully aware of the Behavior Management Policy & Practices and understand the importance of taking responsibility for my actions. As a member of the Teen Center, I am committing myself to working towards program mission and goals. By signing this document I am agreeing to abide by all policies and procedures of the Teen After School Program. Should I choose not to abide by these policies and procedures, I understand that I may be asked to work with the Teen Center Staff, Director and Parents to correct behavior and/or be dismissed from the program. Participant Director Signature 5

6 TASP PARENTAL SIGN OUT CONSENT FORM TEEN AFTER SCHOOL PROGRAM (5 TH 8 TH GRADE) * Participant signature required PLEASE CHOOSE ONE OF THE FOLLOWING OPTIONS: 6 SELF SIGN OUT I,, (please print parent/guardian name) consent with my signature that my child, (please print participant s name) has permission to sign him/herself out of the Teen After School Program after 5:00 p.m. or designated time of : p.m. (must be before 6:00 p.m.) Once my teen has signed him or herself out I release the Ann Arbor YMCA Teen After School Program and it s staff from any responsibility related to my teen. I understand that when my teen signs him or her self out I am taking full responsibility for their actions from that point on. I understand that disregarding the terms outlined herein may result in the dismissal of my teen from the Teen After School Program. I, the participant, understand and agree to follow the expectations listed above. Participant Signature Director Signature PARENT PICK UP ONLY As the Parent/Guardian of (please print) I choose to sign my child in and out of the Teen After School Program or have someone designated in writing to pick up my child. My teen does NOT have permission to sign themselves out of the Teen Center Program. Only the people listed below have permission to sign out your child with valid identification. When signing out a child, the designated adult must present a valid form of identification with photo to the Teen After School Program Staff in order for child to be released. Name #1: Phone: _ Name #2: Phone: _ Name #3: Phone: Director Signature As the parent/guardian of the TASP participant, I authorize the option to call the Teen Center and have a Teen Center Staff release my child from the Teen Center where they are then able to walk themselves out of the building. Parent Signature

7 TASP MONTHLY AUTOMATED PAYMENT AGREEMENT TEEN AFTER SCHOOL PROGRAM (5 TH 8 TH GRADE) PARTICIPANT S NAME: SCHOOL OF ATTENDANCE: NAME(S) OF PARENT/GUARDIAN(S): MAILING ADDRESS: CITY: STATE: ZIP: PHONE: AGREEMENT 1. The Ann Arbor YMCA monthly debit is a continuous payment plan and will be processed on the 20th of each month. I understand that this plan will remain in effect until I wish to terminate my YMCA Teen After School Program care or until the end of the school year (school-age care only). 2. I authorize the Ann Arbor YMCA to draft my account for any late pick-up charges which I may incur while participating in the Teen After School program. 3. It is my complete understanding that if I wish to terminate or change care in any way, I must give the Ann Arbor YMCA Teen Department 20- DAYS WRITTEN NOTICE prior to my next debit date. If proper notice is not received, I will be held responsible for tuition regardless of whether or not my child attends the Ann Arbor YMCA Teen After School Program. 4. Should any debit not be honored by my back/credit card company for any reason, I understand that I am still responsible for the payment, plus a $25.00 service charge applied by the Ann Arbor YMCA. This is in addition to any service fee my bank/credit card company may require. PAYMENT PLEASE SELECT ONE OF THE FOLLOWING METHODS OF AUTOMATED PAYMENT TYPES: CREDIT CARD DRAFT First month s payment will be charged upon registration. Credit Card Type (please circle one): VISA MASTERCARD DISCOVER AMERICAN EXPRESS Name of Cardholder (as it appears on card): Card Number: Exp. of Card: I (we) hereby authorize the Ann Arbor YMCA do debit the above credit card on the date and for the amount indicated each month for my child care services. Authorizing Signature BANK DRAFT In order for a bank draft to be set up, a voided check must be provided in addition to first month s payment upon registration. Depository Name (bank): Account Number: Routing/Transit Number: Name(s) on Account (please print): I (we) authorize the Ann Arbor YMCA to initiate debit entries to my/our account on the date and for the amount indicated on each month for me child care services. Authorizing Signature We accept publicly funded childcare subsidies. If you are on DHS, a current DHS form must be on file naming the YMCA as care provider. If you receive funds from Child Care Network, a current contract needs to be on file naming the YMCA as care provider. See the Parent handbook of call our office for more information on these services at

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9 PERMISSION & HEALTH FORM Teen After School Program 2015/16 LAST NAME: FIRST NAME: DATE OF BIRTH: / / SECTION 1: CONTACT INFORMATION Primary Parent Guardian: Home Address: Home Phone: Work/Cell: Employer/School Name: Employer Address: Employer Phone: Daily Work Times: Secondary Parent Guardian: Home Address: Home Phone: Work/Cell: Employer/School Name: Employer Address: Employer Phone: Daily Work Times: Emergency Contact information: Name: Relationship: Home Phone: Work/Cell: Address: _ SECTION 2: AUTHORIZATIONS (MUST BE COMPLETED TO PARTICIPATE) Field Trip Permission: I give permission for my child, to go on any field trips supervised by the Ann Arbor YMCA Staff. I understand that many trips consist of short walks to nearby locations as well as other short trips within Washtenaw County. I understand further that I will be notified in advance about any longer trips and that, if any vehicle is used to transport my child, each child will be required to wear a seat belt or be placed in a car seat that I would provide. Photography and Recording Permission: I hereby irrevocably release, consent and allow the Ann Arbor YMCA and its agents to use and reproduce any and all photographs or video footage taken of me or my dependent(s) for Ann Arbor YMCA purposes. I understand that I/my dependent(s) receive no reimbursement for allowing my photo to be taken or for the use of the photo or video. Liability: I understand the physical activities which my child may participate in at the YMCA include, but may not be limited to: swimming, mountain biking, and playing sports. I agree to assume all liability and release the YMCA from any liability for the risk of injury, illness or death on account of my child s presence in a YMCA facility or on account of my child s involvement in any activity at a YMCA facility whether caused by negligence of the YMCA or another person on the premises or at the sponsored activity. Swimming: I give permission for my child, to swim during planned trips to the pool. A lifeguard will always be present when my child swims during a YMCA program. OVER 9

10 PERMISSION & HEALTH FORM Teen After School Program 2015/16 LAST NAME: FIRST NAME: DATE OF BIRTH: / / SECTION 3: MEDICATION (All medications must be sent in original containers) The participant takes the following routine medications (including over-the-counter/non-prescription medications) Name of Medication Strength (e.g. "100 mg") Dosage (e.g. "12 pills") Prescribing Physician Reason for taking Other instructions The participant takes the following medications AS NEEDED (includes inhalers, epi-pens, oral medications, topical medications or skin medications) Name of Medication Strength (e.g. "100 mg") Dosage (e.g. "12 pills") Prescribing Physician Reason for taking Other instructions SECTION 4: ALLERGIES/DIETARY RESTRICTIONS (To medicine, food, insect bites, etc.): Allergy Reaction Management of Reaction SECTION 5: PARTICIPANT S HEALTH CARE PROVIDER Name of preferred hospital in event of emergency: Primary Care Physician or Health Clinic: Address: Phone: Health Insurance Carrier: Policy #: SECTION 6: PERMISSION TO TREAT (REQUIRED FOR PARTICIPATION) I give permission to the Ann Arbor YMCA, licensed by the Department of Human Services, to provide routine health care, dispense medications and secure emergency medical and/or emergency surgical treatment to my child while in care. 10